Healthcare Provider Details

I. General information

NPI: 1619047305
Provider Name (Legal Business Name): ST. MICHAEL'S MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 05/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8449 W SHAW BUTTE DR
PEORIA AZ
85345-8160
US

IV. Provider business mailing address

8449 W SHAW BUTTE DR
PEORIA AZ
85345-8160
US

V. Phone/Fax

Practice location:
  • Phone: 623-486-5987
  • Fax: 623-328-5530
Mailing address:
  • Phone: 623-486-5987
  • Fax: 623-328-5530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH-5308
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH6365
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberALH-4384
License Number StateAZ

VIII. Authorized Official

Name: MRS. TERESITA ARCENA CABACUNGAN
Title or Position: OWNER
Credential:
Phone: 562-673-3214